Rehabilitation of anterior cruciate ligament rupture of knee joint

? The anterior cruciate ligament has almost no blood vessels. Its nutrition is provided by synovial fluid in the joint capsule and capillary network attached to the ligament surface. Therefore, after the anterior cruciate ligament is broken, it cannot heal itself. Simply sewing together can't grow together, even if there is a scar connection, it will not be strong and can't bear normal stress.

? Moreover, six weeks after the rupture of the anterior cruciate ligament, it was an old injury. At this time, ligaments are usually dissolved and absorbed in joint fluid. Therefore, after anterior cruciate ligament injury of knee joint, ligament reconstruction surgery is usually needed to restore its function.

? Ten years ago (before the popularization of arthroscopy), the reconstruction of anterior cruciate ligament needed to be completed by cutting off the joint. Make an S-shaped incision around the medial patella in front of the knee joint, and open the patella to expose the whole knee joint. Imagine that the trauma of the operation is great, the patient's pain is great, and the functional rehabilitation after the operation is also very difficult and takes a lot of time. Poor treatment will leave many sequelae and cause new dysfunction. Now, for some insurmountable reasons, we can operate through incision, but with the maturity and development of surgical technology and special instruments, the incision and trauma are still much smaller.

Nowadays, medical technology is more advanced, and knee arthroscopy has been widely used in the world for minimally invasive surgery under microscope. Reconstruction of anterior cruciate ligament with autologous or allogeneic tendon can restore the physical structure of ligament and the normal function of knee joint.

? The specific operation methods and contents are very professional and need relevant knowledge to understand, so I won't introduce them in detail here. But in order to understand the following rehabilitation exercises, you can use some pictures to understand what the operation looks like.

As I said just now, at present, the anterior cruciate ligament is reconstructed with "autologous or allogeneic tendons", so the different "tendons" are used and the surgical methods are different. In the past, it was "popular" to use the middle of your patellar tendon 1/3 (the thick and strong tendon connected below the patella) as the material. However, the pain in front of the patella is often left behind after surgery, and the strength of stretching the knee will be lost to a certain extent, so there are fewer and fewer special needs now.

At present, the most commonly used is to use the tendon of your own hamstring muscle. The so-called hamstring muscle is a large muscle group behind the thigh responsible for knee flexion. When you bend your leg actively, you can feel the hamstring muscles behind your thighs contract and harden. When a new anterior cruciate ligament is reconstructed, two tendons in the hamstring muscle will be taken out, folded in half and woven into a ligament. Therefore, some patients will feel pain in the back of the knee joint when they bend their legs actively after surgery, because the tendon there will take some time to heal. Take the initiative to exert yourself before it heals, and you will feel pain.

Of course, there are other people's allogenic tendons and tendons in other parts as ligaments. Moreover, artificial materials are also used to make new anterior cruciate ligament, which will not be explained here.

After the tendon is removed, it is necessary to select the correct top and bottom dead points with a special locator, then the bone tunnel (in short, drilling holes in the bone), and then fix the new ligament with internal screws to rebuild the new anterior cruciate ligament.

The following is a schematic diagram of the operation:

Schematic diagram of different fixation methods of ligament and postoperative X-ray film;

? Look at it, it only takes a few words to finish, it looks very simple. In fact, the record of the operation is much longer than this. Because it is easy to understand, all the professional and technical related parts are ignored, and there is no mention of how to operate at all. It only describes the general meaning, so it makes very difficult and complicated operations look easy. It's probably a bit like telling a story. What is said here is "cold comes and summer goes, and ten years have passed in a blink of an eye". In fact, all the hardships and complexities have been brushed aside. Taking the choice of ligament anchorage as an example, it can be said that a little forward or backward ligament may be too loose or too tight to affect its function!

After the ligament reconstruction is completed, it is the place for postoperative rehabilitation.

Rehabilitation after arthroscopic anterior cruciate ligament reconstruction can be divided into four stages.

First, the initial stage: that is, the inflammatory reaction period. It is about the first three days after operation, and the longest is the end of the first week. At this stage, the operation has just been finished, the tissue wound has not healed, and there is a tendency of bleeding. There is also a risk of venous thrombosis. Because of inflammation, the pain is obvious, and because of the pain, the muscles can't move, and the muscles will shrink quickly. There are many such problems.

Therefore, the purpose of early rehabilitation is: to relieve joint pain and lower limb swelling; Early isometric muscle strength exercise to avoid excessive atrophy of leg muscles; Early passive exercise of joint mobility to avoid joint adhesion (the specific mechanism is written in "Why does the knee joint adhere?" "inside); There is also early weight bearing to restore proprioception and joint control ability as soon as possible (there is still controversy on this point, and some theories think it will be negative after a few weeks) and to avoid the degeneration of articular cartilage without load bearing capacity.

Second, the early stage: it is the stage when the newly-built ligament and the surrounding bone tissue initially heal and grow together. About the second week to the fourth week after operation. During this period, the upper and lower dead points of the new ligament will have a preliminary fiber healing with the bone canal, and at the same time, it should adapt to the environment in the knee joint. This is the same as people. When you arrive at a new place, you must adapt to the new environment and gain a firm foothold.

? The tasks of rehabilitation at this stage are: strengthening the exercise of the range of motion of the knee joint and gradually restoring the flexion and extension function of the knee joint; Strengthen the exercise of leg muscle strength to lay a good foundation for daily life functions such as walking in the fields; At the same time, it is necessary to improve the control ability and stability of knee joint; People who can bear the load should gradually improve their gait (that is, walking posture).

Third, the middle stage: refers to the fifth week to three months after operation. At this stage, the newly-built anterior cruciate ligament should be better "rooted", that is, the upper and lower dead points should achieve bony healing. At the same time, it needs to grow and transform in the joint environment, so that it can be competent for new tasks, and transform from tendons elsewhere into the morphological structure and function of anterior cruciate ligament (of course, it is as close as possible, and it is impossible to completely transform).

? The key points of rehabilitation at this stage are: strengthening the range of motion of the knee joint and reaching the same flexion and extension angle as your healthy leg (if you practice the angle too fast, the ligament will stretch too much, leading to relaxation; If you practice too slowly, the surrounding tissues will adhere and contract, and the new ligament will not be reconstructed well because of insufficient stress); Strengthen the muscle strength of leg muscles and improve joint stability and control ability during exercise; Gradually restore various activities in daily life, such as walking, going up and down stairs, squatting down, jogging in small steps, etc.

4. Late stage: 3-6 months after operation. It can also be called recovery period of motor function. Because this stage is mainly to restore the normal movement function of the knee joint, so that the newly built anterior cruciate ligament can bear the stress brought by various activities.

? Therefore, the contents of rehabilitation at this stage are: comprehensively restoring various activities of daily life; Further strengthen the muscle strength and joint stability of the legs; At the same time, gradually restore motor function.

It should be noted that the new ligaments reconstructed during this period are not strong enough, and the strength of leg muscles usually has not reached the level of normal legs, so all exercises and exercises must be carried out step by step, and never rashly try to move or resume exercise. The key point should be to continue to strengthen the muscle strength of the muscles around the knee joint to ensure the stability and safety of the knee joint in sports. You can also wear knee pads to protect yourself if necessary. Only after passing professional examination and evaluation (such as ligament tightness and knee flexion and extension muscle strength inspection, etc.). Can you really rest assured to resume exercise?

The above briefly introduces the reconstruction of anterior cruciate ligament of knee joint and the different emphasis of functional rehabilitation at different stages after operation. The following article will specifically talk about the "rehabilitation function exercise plan after arthroscopic anterior cruciate ligament reconstruction".

It should be noted that different hospitals use different surgical methods, and the specific situation of each person's injury is also different, so the timing and methods of postoperative rehabilitation exercise will be different accordingly. Moreover, in order to be easy to understand, the above introduction does not use any technical terms, nor does it elaborate its mechanism and principle in detail. To put it simply, when dividing the stage, it is also distinguished according to the different functional exercises, and there is no specific mention of tissue healing, biomechanics and other factors. So don't think that the recovery of tissue structure and function after anterior cruciate ligament reconstruction is as simple as several stages and a few words!